Some Educational Implications of Childhood Cancer.

R si fearc^ into the social and psychological effects of *ness on children with such chronic diseases as hrria, diabetes, haemophilia and cystic fibrosis is inclusive; some studies (Olch, 1971; Gayton and Friedar|, 1974) indicate that these children often fall short of Q'r educational potential, but others .(Burton, 1974; J0rmina et al, 1976) suggest that children develop, in ^'n9 strategies, and tend to perform at least averagely 1 academic tasks. A similar diversity is to be found in the erature concerning social adjustment (Brown, 1979; ?wles, 1971; Swift, Seidman and Stein, 1967).

INTRODUCTION R si fearc^ into the social and psychological effects of *ness on children with such chronic diseases as hrria, diabetes, haemophilia and cystic fibrosis is inclusive; some studies (Olch, 1971;Gayton and Fried-ar|, 1974) indicate that these children often fall short of Q'r educational potential, but others . (Burton, 1974;J0rmina et al, 1976) suggest that children develop, in ^'n9 strategies, and tend to perform at least averagely 1 academic tasks. A similar diversity is to be found in the erature concerning social adjustment (Brown, 1979;?wles, 1971;Swift, Seidman and Stein, 1967). ^ ?st of the research relating to children with cancer s taken place in America, and although there is some asure of disagreement between the findings of the ^ '?us studies, there is a general consensus that chilin school after treatment for cancer face an in-TgolSec' likelihood of experiencing difficulties (Eiser, Green, 1975;Spinetta, 1980). These potential probes include: Pj ^?or school attendance I behavioural disturbance Non-fulfilment of academic potential.
Th" nis piece of research, which was undertaken as part as a Masters Degree in Education, was designed to C|aSess the re-integration into school and subsequent ha5Sroom performance of a small group of children who suffered from cancer. ^Sample Crjte^amPle of children was identified by the following 2 ^9es between 4 and 11 years (Primary school age). weeks. The mean length of hospitalization for the experimental sample was 6.8 weeks, and for the control group, 5.5 weeks. Time since diagnosis ranged between 1 year and 41/2 years. All the children in the orthopaedic group had undergone surgery, and the children in the oncology group had received radiotherapy and chemotherapy, and two had also undergone surgery. The variety of schools which the children usually attended reflected the diversity of educational provision in the county concerned.

METHODS
Several methods of investigation were employed, these included questionnaires, interviews, rating scales and a standardized test of academic performance. Great care was taken in designing questionnaires and interviews not to refer to the particular circumstances of the child's hospitalization.

RESULTS
The results of the study can be presented in four main sections: a) School Attendance Information regarding attendance at school since hospitalization was gained on visits to the schools. In the experimental group ten children (71%) were reported to have good attendance (80-100 percent), three children (21%) attended fairly well (65-80 percent) and one child had poor attendance (less than 65 percent). This compared with 85% good attendance and 14% fairly good attendance in the control group. Several studies (Eiser, 1980;Green, 1975), and particularly Spinetta 1980) have identified behavioural differences between cancer patients and other children. The modified version of Spinetta's Behavioural Questionnaire which illuminated these differences in the American research, gave the following results (Table 2).
In both groups, the majority of children were rated as stable on the Bristol Social Adjustment Guide. However, where poor adjustment was detected, orthopaedic children tended to over-react and oncology children tended to under-react. Table 3 gives the BSAG ratings.
This tendency is borne out by comments recorded at teachers' interviews three teachers said that their orthopaedic child was attention-seeking, and could be a nuisance; several others commented on lack of concentration, noisiness and naughty behaviour. Teachers of oncology children commented on the quietness of the children, their willingness to help, and their need to do well in class.
The incidence of self-consciousness was high for both groups. For many children, a change in body image has taken place and this may be reflected in the scores. Many teachers noted that the orthopaedic child in their class was physically different perhaps walked with a limp, or was noticably clumsy or 'gawky'; this was without exception linked to the child's operation or condition.
Most children in the oncology group will also have been through physical changes during treatment, although this is usually a temporary change. Nevertheless, the adaptation in body image in order to cope with hair loss, scars, weight gain or loss, and so on, is quite significant. Children undergoing cancer treatment are usually expected to return to school wearing a wig or scarf until the hair grows again; and the change in body size may not stabilize for some time. Thus it is not surprising that the majority of cancer patients and a large minority of orthopaedic patients are rated as behaving in an overly self-conscious way.  cl) y ^(^he'^?rs' Attitudes chik^S att'tucles are seen to be of central importance Vt ren's re-integration into school post-diagnosis, ^'tion LC^ers had been informed about the child's con-^revi0 much time had been missed from school 9dteS u' anc' an 'c'ea treatment used-Two S: bQt? ? sa'd they did not have sufficient informa-sPital c.'1''c'ren had transferred to other schools after Vr rel2at'0n-Several Heads complained that they had 91 or Sr,h0'Ved any medical information from the hospit-Parents J?0's doctor, and that they relied totally on ^Otyn ah ee teachers mentioned that they had not ?ut *he risks involved if the child contracted 0r chicken pox. This vital information had been omitted by parents, or not passed on within the school. Several teachers expressed the need for a channel of communication to be established with the hospital for queries relating to the children. These queries fell into two main categories, and the teachers felt they could not always ask the parents about the issues raised: 1) How much should teachers 'push' the children into taking part in activities, for example should they go out at playtime? Should they be made to do P.E.? How should the children be disciplined? Several teachers said that if they disciplined the child in the same way as the rest of the class, the child might cry, or become withdrawn and pale. Teachers percieved a different reaction in the excancer patient than other children in the class.
2) How much can teachers expect from the children in terms of academic achievement? Had the treatment damaged part of the brain? Could the trauma of lifethreat have affected the child's adjustment and motivation?
The teachers of children in the experimental group were thus aware of a "differentness" of children with cancer. They encouraged parental involvement, and relied on parents for information about medical matters. However, parents of these children were often described as being overprotective.

DISCUSSION
The general conclusion that can be drawn from this study (which is limited by the smallness of the sample), is that primary school age survivors of childhood cancer share some problems common to other children after hospitalization, but that they face further potential difficulties which can be identified as being specific to the condition. Common post-hospitalization problems include short or long-term adjustment difficulty; shortterm academic lag, and longer term problems with such areas of the curriculum which depend on previously understood concepts, for example in mathematics. Additional potential problems identified as being specific to cancer patients are: poor school attendance, lethargy, self-consciousness and anxiety, and under-reactive poor social adjustment.
The study indicates that there are areas of concern with regard to the education of children with cancer. Further research is necessary to clarify whether the conclusions of this study are common to other geographical locations, and across the age range. It also points the way to certain improvements which teachers and others involved in the care and education of children with cancer could implement.
Firstly, channels of communication between hospital medical staff, hospital and home teaching services, and schools, could be made more effective. Parents must retain their current authority, but where possible, they should be encouraged to allow access to relevant information to schools by the usual interdisciplinary methods. Many parents would welcome this approach, as it would relieve them of the burden of conveying medical messages themselves, although they should be included in the process at every level. Access to information about cancer generally, and the effects of the illness and its treatment, on individual pupils, would help teachers understand the condition, and thereby create a foundation from which he or she could handle potentially difficult classroom situations involving the cancer patient or his peers. Teachers' understanding of the child's absences, side effects of therapies and the need for a balance of realistic academic expectations should en-id) 2I) 3I1 iji 5<l 6^ 7(!) ei 90 100 1 0 -120 Flg. , _Scores for the oncology group on reading tests NFER A/BD. Scores for the oncology group on reading tests NFER A/BD. hance the child's chances of positive school experiences, by reducing anxiety and boosting self-esteem. Secondly, hospital and home teaching staff should be made aware of the implications of chronic illness on certain areas of the curriculum. The proportion of children assessed at a below-average level in mathematics is significant (57% and 42% in the two groups of hospitalized children). Hospital and home tutors are frequently in a one-to-one or small-group teaching situation, which could be utilized to assess difficulty and make up any deficit.
Improvements in these two areas may help children with cancer to lead a normal life at school.